New Clinical Practice Guideline for Tonsillectomy
Soham Roy, MD,FACS,FAAP
A tremendous amount of media attention has been paid recently to tonsillectomy surgery in children, partially due to President Obama’s comments on tonsillectomy during the pivotal September 2009 speech to the nation on healthcare reform. “The doctor may look at the reimbursement system and say to himself, ‘You know what? I make a lot more money if I take this kid’s tonsils out,’” the President remarked, followed by: “Now, that may be the right thing to do, but I’d rather have that doctor making those decisions just based on whether you really need your kid’s tonsils out or whether it might make more sense just to change; maybe they have allergies. Maybe they have something else that would make a difference.”
The tonsillectomy operation has been taking place in some form for over 2000 years, since first described by Celsius in 50 AD. While much has changed for the better during that time period, until recently no clear evidence-based guideline existed for decision-making about tonsillar surgery in children, and parents and their otorhinolaryngologists made decisions about tonsil surgery based on the best available knowledge and practice. In January 2011, the American Academy of Otolaryngology released a Clinical Practice Guideline (Oto-HNS, v144 S1, January 2011) to help physicians and parents navigate a maze of data and help better understand the clear indications for surgery, identify children who are the best candidates for tonsillectomy surgery, and to optimize the care (both before and after) of children undergoing tonsillectomy.
The clinical guideline incorporated the research and thoughts of panelists including otorhinolaryngologists, pediatricians, family medicine doctors, anesthesiologists, infectious disease specialists, sleep medicine specialists, nurses, and healthcare consumers to review the literature and data and produce these recommendations. Well-crafted guidelines like these improve quality, improve outcomes, minimize risks and dangers, and reduce wide variations in care when implemented, which improves the understanding and education of families who are considering tonsillectomy surgery for their children. This is the first and only evidence-based national practice guideline for tonsillectomy surgery in the US.
Tonsillectomy is the third most commonly performed operation performed on children in the US, with more than 500,000 operations taking place per year (circumcision and ear tubes are the two most common). It represents one in 7 ambulatory surgical operations in pre-teen children. The two most common reasons for tonsillectomy are for frequent throat infections, or sleep disordered breathing due to adenotonsillar hypertrophy (often manifested as snoring and in some cases sleep apnea). When this operation is chosen for the right group of children, it can significantly reduce throat infections, improve sleep quality, daytime functioning, decrease doctor visits and antibiotic use, and most importantly improve a child and a family’s quality of life. However, there is an associated morbidity with the operation that includes hospitalization, financial costs, risks of anesthesia, postoperative bleeding, and scarring. In fact, up to 4% of children may be readmitted for secondary complications, which makes good decision-making for surgery of paramount importance.
The most newsworthy points in the new guideline include these findings.
- This is the first and only national, evidence-based guideline on tonsillectomy in the US.
- Tonsillectomy can improve the quality of life in children by reducing the frequency of sore throats in children who have roughly 7 throat infections over the previous year, 5 infections per year for the past two years, or three per year for the past three years. These infections include documentation of temperature> 38.3C, cervical adenopathy, tonsillar exudates, or positive testing for Group A Beta-hemolytic Strep (GABHS). These criteria provide an option for recommendation.
- Those numbers, however, are guidelines and suggestions, not strict or hard-and-fast rules. Some children who don’t meet those exact numbers of infections may still benefit from surgery if they have other factors including severe infections requiring missed school, inability to tolerate antibiotics, or an history of complications such as peritonsillar abscess. If a child does not meet those criteria listed above, other modifying factors such as PFAPA (Periodic fever, aphthous stomatitis, pharyngitis, and adenitis), antibiotic allergy/intolerance, or PTA should be considered in making the decisions about surgery.
- Most children with less frequent throat infections – fewer than the numbers suggested above – will get better on their own. In those children, watching and waiting is the preferred approach to surgery, as surgery has associated risks and should be used for the more severely ill children. Watchful waiting is recommended if fewer than those numbers of infections are met without modifying factors.
- Children with enlarged tonsils – which has no relation to the number of infections – may have trouble breathing at night as a result of enlarged tonsils causing obstruction. This obstruction can lead to snoring, mouth breathing, pauses in breathing or periods of obstructive apnea. Children may have very enlarged tonsils causing snoring even without any history of infections, and children with very small tonsils may still have frequent infections even if the tonsils aren’t enlarged or causing those problems.
- Children who have enlarged tonsils and any of the breathing problems noted during sleep may also have associated daytime problems such as growth delay, prolonged bedwetting, behavioral problems and poor school performance. These problems may improve after tonsillectomy surgery in certain children. It is recommended that clinicians ask questions of parents about comorbid conditions that may improve after tonsillectomy including growth retardation, poor school performance, enuresis and behavioral problems.
- Children with other risk factors for snoring or interrupted sleep – children who are overweight, have Down syndrome or other malformations of the face or skull – may not improve with just tonsillectomy surgery alone and may need other treatment. Parents should be counseled that sleep disordered breathing may persist after tonsillectomy and require other forms of management.
- A single intraoperative dose of steroids (dexamethasone) is strongly recommended for children undergoing tonsillectomy to reduce postoperative nausea and vomiting, reduce throat pain and improve oral intake.
- Antibiotics are no longer routinely given after tonsillectomy surgery. While this was traditionally done in the past, there is no data that shows consistent benefits for post-surgical antibiotics and those medications do have risk involved. It is strongly recommended against administration or prescribing of antibiotics in the perioperative period.
- Recovery remains an uncomfortable period after the surgery, with pain lasting up to 2 weeks after the surgery. Managing the pain includes giving the child adequate pain medicines early and regularly, encouraging the child to let the parents know when the throat hurts after surgery, and drinking plenty of fluid. It is recommended that clinicians counsel family members about the importance of managing and re-assessing pain after the surgery frequently.
- Anyone who performs the surgery should evaluate their own rates of primary and secondary posttonsillectomy hemorrhage on an annual basis.
- Importantly – any surgery, elective or emergency, has risks involved. Even though tonsillectomy surgery is performed frequently and is relatively low-risk, it carries with it some risks of complications, including bleeding during the recovery period, changes in voice, and other unforeseen complications. There is no operation that is absolutely risk-free. Parents should consider tonsillectomy surgery for their children only after carefully weighing the risks of surgery, even though the risks may be small, against the potential benefit their child stands to gain.
- Most of all, for parents considering the surgery, ask questions. As a parent, it is fundamentally important to be actively involved in every aspect of your child’s health care. You make the decisions that are best for your child – your ENT physician is there to guide you through the information, make suggestions and recommendations, and highlight the benefits and risks of different treatments whether it is a “wait and see” approach, medications, or surgery.